Sympazan (clobazam) — CareFirst (Caremark)

Initial criteria

• The requested drug is being prescribed for the treatment of seizures associated with Dravet syndrome
• The request is for Onfi (clobazam) OR Sympazan (clobazam)

Reauthorization criteria

• The requested drug is being prescribed for the treatment of seizures associated with Dravet syndrome
• The request is for Onfi (clobazam) OR Sympazan (clobazam)
• The patient has achieved and maintained positive clinical response as evidenced by reduction in frequency or duration of seizures compared with seizure activity prior to initiation of the requested drug

Approval duration

36 months